Uveítis asociada a la artritis idiopática juvenil / Uveitis associated to juvenile idiopathic arthritis

Objetivo: Caracterizar las uveítis asociadas a la artritis idiopática juvenil. Métodos: Se realizó un estudio observacional, descriptivo, de corte transversal, donde se evaluaron las variables edad, raza, sexo, lateralidad de la uveítis, clasificación anatómica, agudeza visual mejor corregida, presencia de complicaciones y tratamiento. Resultados: Predominaron los mayores de seis años, el sexo femenino y la raza blanca. En cuanto a la lateralidad hubo mayor predominio de las bilaterales, con localización anatómica anterior. En los resultados visuales sobresalieron los que presentaban una agudeza visual mejor corregida ≥ 0,5. Las complicaciones más frecuentes fueron: la pérdida visual, la hipertensión ocular y la queratopatía en banda. Con respecto al tratamiento, la mayoría de los pacientes tenían asociado metotrexate al tratamiento tópico y oral con esteroides. Conclusión: La uveítis asociada a la artritis idiopática juvenil sigue siendo un problema importante de salud en la infancia a pesar de los avances en los programas de atención a esta enfermedad; por tanto, el diagnóstico precoz, el seguimiento estricto y el tratamiento adecuado son los pilares para una mejor evolución(AU)

Objective: Characterize uveitis associated to juvenile idiopathic arthritis. Methods: A cross-sectional observational descriptive study was conducted based on evaluation of the following variables: age, race, sex, laterality of uveitis, anatomical classification, best corrected visual acuity, presence of complications and treatment. Results: A predominance was observed of patients aged over six years, female sex and white race. Bilateral uveitis prevailed, with anterior anatomical location. Patients with a best corrected visual acuity ≥ 0.5 stood out for their visual results. The most common complications were visual loss, ocular hypertension and band keratopathy. Most patients had methotrexate associated to topical and oral treatment with steroids. Conclusion: Uveitis associated to juvenile idiopathic arthritis continues to be an important health problem in childhood, despite the progress in the care of this condition. Therefore, early diagnosis, strict follow-up and appropriate treatment are the pillars of a better evolution(AU)

Impacto psicosocial y económico de la uveítis en México / Psychosocial and economic impact of uveitis in Mexico

Resumen Objetivo: Conocer el impacto psicosocial y económico quede la uveítis en México. Métodos: Encuesta en pacientes diagnosticados con uveítis. Se registraron datos demográficos y nivel socioeconómico. Se identificaron síntomas, tiempo al diagnóstico, tratamiento, comportamiento, actitudes y sentimientos ante la enfermedad. Resultados: Se realizaron 100 encuestas a pacientes con uveítis, con edad media de 45 ± 17.08 años, nivel socioeconómico ≤ D; 54 eran mujeres. El diagnóstico se realizó al 1.87 ± 2.73 años. Acuden anualmente a cita 2.1 ± 2.14 mes, más de 1 a urgencias y son hospitalizados 3.7 días. Utilizan tratamiento sistémico con antiinflamatorios esteroideos (53 %), inmunosupresor (31 %), terapia biológica (7 %), tratamiento tópico con lubricantes (44 %), esteroides (26 %) y cirugías (39 %). Comorbilidades observadas: hipertensión arterial, diabetes mellitus, artritis reumatoide (18 %), síndrome de Sjögren, lupus y colitis ulcerativa crónica inespecífica. Complicaciones: deterioro visual, cataratas y ceguera. La uveítis afecta su vida en el 83 % de los casos, en el 41 % a diario y el 49 % necesitan cuidados de otra persona. El 79 % reciben atención privada, el 43 % cuenta con seguridad social, gastando mensualmente $3,590 ± $2,730.65 pesos en medicamentos, transporte, consulta médicas y estudios. Anualmente con ausentismo laboral de 8.5 ± 14.56 días, más 7.0 días de incapacidad u hospitalización. El 51 % refieren falta de apoyo para conocer la enfermedad. Conclusiones: Se trata del primer estudio nacional que escenifica la condición de los pacientes con uveítis y las insuficiencias por las que atraviesan, incluyendo el ámbito económico y biopsicosocial.

Abstract Objective: Determine the psychosocial and economic impact suffered by patients diagnosed with uveitis in Mexico. Methods: Survey in uveitis-diagnosed patients. Demographic data and socioeconomic level were recorded. Symptoms, time to diagnosis, type of treatment, behavior, attitudes and feelings towards the disease were identified. Results: One hundred surveys were conducted in patients with uveitis, who had a mean age of 45 ± 17.08 years, and socioeconomic level ≤ D; 54 were females. Diagnostic delay was 1.87 ± 2.73 years. Annually, patients attend 2.1 ± 2.14 appointments per month, and are admitted once to the emergency department and remain hospitalized for 3.7 days. Patients use systemic treatment with steroidal anti-inflammatory drugs (53 %), immunosuppressant agents (31 %), biological therapy (7 %), topical treatment with lubricants (44 %) or steroids (26 %) and undergo surgery (39 %). Observed comorbidities include hypertension, diabetes mellitus, rheumatoid arthritis (18 %), Sjögren’s syndrome, systemic lupus erythematosus, and nonspecific chronic ulcerative colitis. Complications: visual impairment, cataracts and blindness. Uveitis affects their life in 83 % of cases, in 41 % does it daily, and 49 % need care from another person. Seventy-nine percent receive private care and 43 % have social security, with $ 3,590 ± $ 2,730.65 pesos being spent monthly on medicines, transportation, medical appointments and studies. Annually, work absenteeism is 8.5 ± 14.56 days, plus 7.0 days of disability or hospitalization; 51% refer lack of support to learn about the disease. Conclusions: This is the first national study to portray the condition of patients with uveitis and the shortcomings they go through, including the economic and biopsychosocial fields.

Sífilis, la gran simuladora / 8 SYPHILIS, THE GREAT SIMULATOR. Case report of a patient with syphilitic uveitis

La sífilis desde hace siglos desafía a la humanidad, es transmitida por vía sexual y verticalmente durante la gestación.9 Esta enfermedad se hizo conocida en Europa a finales del siglo XV,13 y su rápida propagación por todo el continente la transformó en una de las principales plagas mundiales.Era preocupante el crecimiento de la endemia sifilítica en el siglo XIX 13.1. En contrapartida la medicina se desarrollaba, y la síntesis de las primeras drogas se hacía realidad. El mayor impacto tal vez fue la introducción de la penicilina en 1946, la cual por su eficacia hizo a muchos pensar que la enfermedad estaba controlada. En un estudio de revisión de literatura se dice que a raíz de la introducción de la penicilina la incidencia de sífilis (y de uveítis sifilítica) fue disminuyendo constantemente hasta finales de los años 90.3 resultando en la disminución del interés por su estudio y control. Con la aparición del síndrome de inmunodeficiencia adquirida (SIDA).2 se incrementó dramáticamente la evolución de esta enfermedad.En la literatura oftalmológica se comenzaron a documentar cada vez más casos e incluso se ha llegado a hablar de la «nueva epidemia de sífilis ocular¼1 Se estima que, anualmente, unos 357 millones de personas contraen alguna de las cuatro infecciones de transmisión sexual (ITS) siguientes: clamidias, gonorrea, sífilis o tricomoniasis.7 En el mundo hay una incidencia anual de aproximadamente 12 millones de pacientes con sífilis el 90% ocurre en países en desarrollo (OMS).

Syphilis has defied humanity for centuries, is transmitted sexually and vertically during pregnancy. This disease became known in Europe at the end of the 15th century,13 and its rapid spread throughout the continent transformed it into one of the main world plagues. The growth of the syphilitic endemic in the 19th century was worrisome.13.1 In contrast, medicine developed, and the synthesis of the first drugs became a reality. Perhaps the biggest impact was the introduction of penicillin in 1946, which, due to its effectiveness, led many to believe that the disease was controlled. In a literature review study, it is said that following the introduction of penicillin the incidence of syphilis (and syphilitic uveitis) was steadily decreasing until the end of the 90s.3 resultando in the decrease of interest in its study and control. With the onset of acquired immunodeficiency syndrome (AIDS). the evolution of this disease increased dramatically. In the ophthalmological literature, more and more cases have been documented and there has even been talk of the "new epidemic of ocular syphilis".1.1 It is estimated that some 357 million people each year get one of the four sexually transmitted infections (STIs) following: chlamydia, gonorrhea, syphilis or trichomonas's. In the world there is an annual incidence of approximately 12 million patients with syphilis 90% occurs in developing countries (WHO)

Usefulness of aqueous and vitreous humor analysis in infectious uveitis

OBJECTIVE: To evaluate the role of intraocular fluid analysis as a diagnostic aid for uveitis. METHODS: Twenty-eight samples (27 patients including 3 HIV-infected patients) with active (n=24) or non-active (n=4) uveitis were submitted to aqueous (AH; n=12) or vitreous humor (VH) analysis (n=16). All samples were analyzed by quantitative PCR for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Toxoplasma gondii. RESULTS: The positivity of the PCR in AH was 41.7% (5/12), with 50% (2/4) in immunocompetent and 67% (2/3) in HIV+ patients. The positivity of the PCR in VH was 31.2% (5/16), with 13% (1/8) in immunocompetent and 50% (4/8) in immunosuppressed HIV negative patients. The analysis was a determinant in the diagnostic definition in 58% of HA and 50% of VH. CONCLUSION: Even in posterior uveitis, initial AH analysis may be helpful. A careful formulation of possible clinical diagnosis seems to increase the chance of intraocular sample analysis being meaningful.

Aspectos clínicos e tratamento de pacientes com tuberculose ocular presumida em centro de referência de São Paulo, Brasil. Estudo retrospectivo / Clinical description and treatment of patients with presumed ocular tuberculosis in São Paulo, Brazil. Retrospective study

Resumo Objetivo: Descrever aspectos clínicos e esquema terapêutico dos pacientes com tuberculose ocular presumida tratados em um centro de referência em tuberculose de São Paulo. Métodos: Estudo retrospectivo descritivo. O teste exato de Fisher foi realizado quando apropriado. Resultados: A queixa mais comum foi baixa acuidade visual (83,1%), seguida por dor ocular generalizada (25,3%) e visão turva (22,8%). A uveíte posterior foi a apresentação mais comum (35,7%). O tratamento consistiu no esquema atualmente recomendado de rifampicina, isoniazida, pirazinamida e etambutol (RHZE). A prednisona oral foi incluída no tratamento de 37 pacientes, para tratamento da inflamação aguda, embora não tenha diminuído a prevalência de complicações crônicas, em comparação com a recuperação completa (p = 0,1). O diagnóstico precoce (<70 dias) foi associado a maiores taxas de recuperação total (p = 0,005). Não houve significância estatística quando se comparou a terapia de 6 a 9 meses (p = 0,7). Conclusão: A uveíte tuberculosa pode ser tratada por uma terapia com duração de seis meses. Um breve curso de esteroides melhora os sintomas agudos, embora não reduza as complicações a longo prazo.

Abstract Purpose: To analyze and describe the therapy used in presumed ocular tuberculosis in a referral center in São Paulo, Brazil. Methods: Retrospective, descriptive study. Fisher's exact test was performed when appropriate. Results: The most common complaint was low visual acuity (83.1%), followed by generalized ocular pain (25.3%) and blurred vision (22.8%). Posterior uveitis was the most common presentation (35.7%). Treatment consisted of the currently recommended association of rifampin, isoniazid, pyrazinamide, ethambutol (RHZE) regimen. Oral prednisone was included in the treatment of 37 patients for acute inflammation, although it did not significantly decrease the prevalence of chronic complications compared to full recovery (p = 0,1). Early diagnosis (< 70 days) was associated with higher rates of full recovery (p = 0.005). No statistical significance was observed when comparing 6 to 9-month therapy (p = 0.7). Conclusion: Tuberculous uveitis can be treated with a 6-month duration RHZE therapy. A brief course of steroids may improve acute symptoms, although it did not reduce long-term disabilities.

Potencial do teste IGRA (Interferon Gama Release Assay) para o diagnóstico de tuberculose ocular. Revisão e análise comparativa com o teste tuberculínico cutâneo (PPD) / The potential of the IGRA (Interferon Gamma Release Assay) test for the diagnosis of ocular tuberculosis. Review and comparative analysis with the tuberculosis skin test

Resumo A detecção precisa da infecção latente por tuberculose está se tornando cada vez mais importante devido ao aumento do uso de medicamentos imunossupressores e da epidemia do vírus da imunodeficiência humana, o que aumentou o risco de reativação à tuberculose ativa (TB). O Teste IGRA QuantiFERON® TB Gold apresenta vantagens frente ao teste de PPD como por exemplo, requer somente uma coleta de amostra sanguínea ; não há necessidade que o paciente retorne ao laboratório para leitura e interpretação dos resultados; Os resultados são objetivos, não requerem interpretação do leitor ou interferência de critérios subjetivos; trata-se de um teste in vitro, portanto não há "efeito booster" (potenciação da reação tuberculínica); o teste não é afetado por vacinação prévia por BCG ou infecção por outras espécies de micobactérias. Limitações são descritas, apesar de raras, como reações cruzadas deste método com infecções por algumas espécies de micobactérias não-tuberculosis (incluindo Mycobacterium kansasii, Mycobacterium szulgai e Mycobacterium marinum). Ainda há poucos dados sobre o teste IGRA em certas populações, como por exemplo, em crianças, pacientes imunocomprometidos e mulheres grávidas. Nestes grupos, a interpretação do teste pode ser difícil e mais estudos se fazem necessários.

Abstract Precise detection of latent tuberculosis infection is becoming increasingly important due to increased use of immunosuppressive drugs and the human immunodeficiency virus epidemic , which increased the risk of reactivation to active tuberculosis (TB).The QuantiFERON® TB Gold IGRA Test has advantages over the skin test for TB, otherwise known as a Mantoux tuberculin test, for example, requires only a blood sample collection; there is no need for the patient to return to the laboratory for reading and interpretation of the results; The results are objective, do not require interpretation of the reader or interference of subjective criteria; it is an in vitro test, so there is no "booster effect" (potentiation of the tuberculin reaction); the test is not affected by prior BCG vaccination or infection with other species of mycobacteria. Limitations are described, although rare, as cross-reactions of this method with infections by some species of non-tuberculosis mycobacteria (including Mycobacterium kansasii, Mycobacterium szulgai and Mycobacterium marinum). There is still little data on the IGRA test in certain populations, such as in children, immunocompromised patients and pregnant women. In these groups, the interpretation of the test can be difficult and more studies are needed.

Tubulointerstitial nephritis and uveitis syndrome in children: report of three cases / Nefrite tubulointersticial e uveíte em idade pediátrica: descrição de três doentes

ABSTRACT Tubulointerstitial nephritis and uveitis syndrome is a rare and probably underdiagnosed condition. Renal and ocular manifestations may not occur simultaneously, making the diagnosis more difficult. Nephritis may be asymptomatic; therefore, renal function evaluation is essential for diagnosis. Urinary β2-microglobulin levels may be particularly useful. Uveitis, mostly anterior, nongranulomatous and bilateral, occurs usually after the onset of nephritis. Treatment includes corticosteroids and, eventually, other immunosuppressant agents. Renal disease is usually benign and resolves spontaneously or after treatment with systemic corticosteroids. Uveitis, however, may be chronic or recurrent. The authors described the cases of three pediatric patients diagnosed with tubulointerstitial nephritis and uveitis syndrome. The goal of this paper was to warn the medical community over the need to screen patients with uveitis for renal disease.

RESUMO A síndrome nefrite tubulointersticial e uveíte é uma doença rara, provavelmente subdiagnosticada. As manifestações renais e oculares podem não ocorrer simultaneamente, tornando o diagnóstico mais difícil. A nefrite é geralmente assintomática, tornando fundamental a avaliação da função renal em doentes com uveíte. O doseamento da excreção urinária de β2-microglobulina é particularmente útil para o diagnóstico. A uveíte, tipicamente anterior, não granulomatosa e bilateral, manifesta-se após a nefrite na maioria dos casos. O tratamento inclui corticoides e, por vezes, outros imunossupressores. A doença renal tem evolução benigna, resolvendo-se espontaneamente ou com terapêutica com corticoides sistêmicos na maioria dos casos, no entanto, a uveíte pode ser crônica ou recorrente. Os autores descrevem três casos de síndrome nefrite tubulointersticial e uveíte, diagnosticados em idade pediátrica, e pretendem alertar para a necessidade de pesquisar sempre alterações renais nos doentes com uveíte.

Análise da frequência de uveítes em pacientes com espondiloartrites, suas complicações e associação com parâmetros clínicos da doença / Analysis of the frequency of uveitis in spondyloarthritis patients and associations with clinical parameters of the disease

Resumo Objetivo: A uveíte anterior aguda é a principal manifestação extra-articular na espondiloartrite. O objetivo deste estudo foi analisar se a presença da uveíte se associa com diferentes manifestações clínicas, laboratoriais, radiológicas e a terapêutica nos pacientes com espondiloartrite. Métodos: Estudo observacional retrospectivo realizado com 153 pacientes portadores de espondiloartrite atendidos no período de 1997 a 2017 na Grande Florianópolis, Brasil. Foram analisados dados demográficos, laboratoriais, clínicos e do tratamento de pacientes com espondiloartrite em relação a presença ou não de uveíte. Resultados: A uveíte foi encontrada em 26,8% dos pacientes. A presença de complicações foi rara, ocorrendo catarata em somente quatro pacientes e glaucoma em dois deles. Foi observada uma tendência a maior frequência de uveíte anterior aguda no sexo masculino (p=0,06), nos pacientes com história familiar (p=0,19) e HLA-B27 positivos (p=0,14). Pacientes com espondiloartrite e uveíte mais frequentemente usavam anti-TNF (p=0,04) e apresentavam sacroiliite em exames de imagem (p=0,02). Não observou-se associação entre a uveíte e o acometimento cardiovascular (p=0,44), cutâneo (p=0,13) ou gastrointestinal (p=0,10). Conclusão: A uveíte que ocorre em pacientes com espondiloartrite é comum, tem predomínio no sexo masculino e é mais frequente em pacientes com HLA-B27 positivo. O uso de imunobiológicos como o anti-TNF é frequente nos pacientes com uveíte.

Abstract Objective: Acute anterior uveitis (AAU) is the most common extra-articular manifestation of spondyloarthritis. The aim of this study is to analyze if the presence of uveitis is associated with a diferent clinical manifestation, laboratorial, radiological and therapetiuc among spondyloarthritis patients. Methods: This was a observational retrospective study with 153 patients with spondyloarthritis attended in the period from 1997 to 2017 in Florianopolis, Brazil. It was analyzed demografical, laboratorial, clinical and therapeutic data in spondyloarthritis patients with or without uveitis. Results: 26,8% of the patients with spondyloarthritis presented uveitis. The presence of complications was rare, with cataract occurring in only four patients and glaucoma in two of them. A higher frequency of acute anterior uveitis in males (p = 0.06) was observed in patients with a family history (p = 0.19) and HLA-B27 positive (p = 0.14). Patients with spondyloarthritis and uveitis more frequently used anti-TNF (p = 0.04) and presented sacroiliitis on imaging tests (p = 0.02). There was no association between uveitis and cardiovascular (p = 0.44), cutaneous (p = 0.13) or gastrointestinal involvement (p = 0.10). Conclusion: Uveitis in patients with spondylarthritis is common, predominantly in males, and more frequently in HLA-B27 positive patients. The use of immunobiological agents such as anti-TNF is common in patients with uveitis.

Ocular manifestations of leishmaniasis in a cat: first case report from Brazil / Manifestações oculares da leishmaniose em um gato: primeiro relato de caso do Brasil

An 8-year-old domestic short hair female cat initially presented with bilateral uveitis with pseudotumoral appearance. The patient tested negative for feline immunodeficiency virus (FIV), feline leukemia virus (FeLV) and Toxoplasma gondii. Histopathology of a granulomatous lesion on the upper left conjunctiva revealed amastigotes compatible with Leishmania spp. Aqueous humor was aspired and the diagnosis was confirmed after isolation of promastigotes cultivated in biphasic NNN medium and by positive polymerase chain reaction (PCR) for Leishmania infantum. Treatment with allopurinol (10mg/kg/ BID/PO) was commenced and a natural insect repellent was prescribed. Six months of treatment with allopurinol associated with the initial topical medications helped to improve ocular signs. Leishmaniasis should be considered as a differential diagnosis in cats presenting uveitis with pseudotumoral appearance. To our knowledge, this is the first report of feline leishmaniasis with ocular manifestation in Brazil, in which diagnosis was confirmed by aqueous humor analysis.(AU)

Uma gata, sem raça definida, de oito anos de idade, foi atendida inicialmente com uveíte bilateral, com aparência pseudotumoral em íris. Foi realizado teste para o vírus da imunodeficiência felina (FIV), da leucemia felina (FeLV) e de Toxoplasma gondii, obtendo-se resultados negativos. O exame histopatológico da conjuntiva superior do olho esquerdo revelou amastigotas compatíveis com Leishmania spp. Foi realizada paracentese, e promastigotas foram isoladas no humor aquoso, cultivadas em meio NNN bifásica. Reação em cadeia da polimerase (PCR) confirmou diagnóstico positivo para Leishmania infantum. Tratamento com alopurinol (10mg/kg/BID/PO) foi iniciado, e um repelente natural de insetos foi prescrito. Seis meses de tratamento com alopurinol associado aos medicamentos tópicos iniciais ajudaram a melhorar os sinais oculares. Leishmaniose deve ser considerada como um diagnóstico diferencial nos gatos que apresentam uveíte com aparência pseudotumoral de íris. Até o presente momento, este é o primeiro relato de leishmaniose felina com manifestação exclusivamente ocular da doença no Brasil cujo diagnóstico foi confirmado por meio de análise de humor aquoso.(AU)

Acometimento visceral e ocular simultâneo em infecção por toxocara canis acompanhado de farmacodermia / Concurrent visceral and ocular involvementin toxocara canis infection and pharmacodermia

A toxocaríase humana é uma infecção parasitária de distribuição mundial causada pelos nematelmintos das espécies Toxocara canis e Toxocara cati, presentes no intestino do cão e do gato, respectivamente. Clinicamente, na maioria das vezes, é assintomática, porém pode apresentar-se de duas formas: visceral ou ocular. Visceralmente, gera uma síndrome hipereosinofílica crônica, acompanhada por leucocitose e hepatomegalia, podendo ocorrer algum grau de infiltrado pulmonar e febre. Na toxocaríase ocular, ocorre uveite intermediária ou posterior, podendo haver formação de granuloma, geralmente unilateral. O acometimento misto é raro, o que motivou este relato. Trata-se de paciente de 19 anos, sexo masculino, que apresentou como sintoma inicial perda da acuidade visual em olho esquerdo. Recebeu tratamento, sem melhora, com sulfametoxazol + trimetoprima e corticoide, fazendo farmacodermia. Evoluiu com diarreia, febre, dor abdominal e hepatoesplenomegalia. Descartadas infecções agudas por toxoplasmose, sífilis, vírus da imunodeficiência humana (HIV), citomegalovirose e dengue; apresentou leucocitose com hipereosinofilia. Foi solicitada sorologia para toxocaríase, confirmando esta infecção. Após o tratamento, apresentou completa remissão dos sintomas. O objetivo aqui foi debater os fatores confundidores, diagnósticos diferenciais, necessidade de exames complementares específicos e conduta terapêutica, de acordo com o quadro clínico.(AU)

Human toxocariasis is a worldwide parasitic infection caused by ascarid nematodes species: Toxocara canis and Toxocara cati, that are present in the intestines of dogs and cats, respectively. Although clinically, most human infections are asymptomatic, two syndromes of human toxocariasis are recognized: visceral and ocular. The visceral form is a hypereosinophilic syndrome accompanied by leukocytosis, hepatomegaly, some degree of pulmonary infiltrate and fever. In ocular toxacariasis there is intermediate or posterior uveitis, and there may be granuloma formation, usually unilateral. The simultaneous involvement of the two forms is rare, which is what, motivated this report. It is a 19-year-old male patient who initially presented loss of visual acuity in the left eye. He received treatment, without improvement, with sulfamethoxazole-trimethoprim and corticoid, causing a pharmacodermia. He developed diarrhea, fever, abdominal pain and hepatosplenomegaly. It was discarded acute infections by toxoplasmosis, syphilis, human immunodeficiency virus (HIV), cytomegalovirus and dengue. The patient also manifested leukocytosis with hypereosinophilia. Serological testing for toxacariasis was requested, diagnosing the infection. After treatment, he progressed with full symptoms remission. The aim of this study was to discuss confounding factors, differential diagnoses, the need for specific complementary exams and therapeutic management, according to the clinical aspects.(AU)

Toxoplasmosis ocular recurrente. Presentación de 3 casos y revisión de la literatura / RECURRENT OCULAR TOXOPLASMOSIS: REPORT OF 3 PATIENTS AND REVISION OF THE LITERATURE

La toxoplasmosis ocular recurrente es la forma más común de toxoplasmosis ocular. Las lesiones se localizan adyacentes a una cicatriz coriorretinal resultado de una infección previamente adquirida. La retinitis por toxoplasma provoca una respuesta inflamatoria variable, ocasionando vasculitis, vitreítis, coroiditis y uveítis anterior. El diagnóstico se realiza examinando el fondo de ojo, y su etiología debe considerarse cuando en un adulto joven inmunocompetente, se observa en la fundoscopía la presencia de una lesión retinal focal, asociada a una cicatriz coriorretinal. La retinografía permite documentar los hallazgos observados en el fondo de ojo. El examen serológico para identificar anticuerpos anti toxoplasma de clase IgM e IgG solo confirma la exposición al parásito pero no constituyen pruebas diagnósticas confirmatorias. Se presentan 3 casos de toxoplasmosis ocular recurrente en pacientes adultos cuyos diagnósticos se realizaron mediante el examen fundoscópico y la retinografía.

Recurrent ocular toxoplasmosis is the most common form of ocular toxoplasmosis. Lesions are located adjacent to a chorioretinal scar as a result of a previously acquired infection. Toxoplasma retinitis produces a variables inflammatory response, leading to vasculitis, vitreitis, choroiditis and anterior uveities. Diagnosis is performed by fundoscopy and its ethiology must be considered when fundoscopy shows the presence of a focal retinal lesion associated to a chorioretinal scar in a young immunocompetent adult. Retinography allows documenting findings from the fundoscopy. Serological examination to identify anti toxoplasma antibodies classes IgM and IgG only confirms exposure to the parasite but do not constitute confirmatory diagnostic evidence. We present 3 cases of recurrent ocular toxoplasmosis in adult patients that were diagnosis by fundoscopic examination and retinography

Análise retrospectiva e caracterização epidemiológica dos casos de uveíte em hospital terciário / Epidemiological analysis of cases of uveitis in a tertiary Hospital

Resumo Objetivo: Analisar a distribuição dos casos de uveíte em pacientes atendidos no Setor de Uveíte do Serviço de Oftalmologia do Hospital Federal Servidores do Estado do Rio de Janeiro. Métodos: Estudo epidemiológico retrospectivo, transversal e descritivo pela análise de prontuários de 63 pacientes atendidos no Serviço de Oftalmologia do Hospital Federal dos Servidores do Estado do Rio de Janeiro, no Setor de Uveíte, no período de Março a Outubro de 2016. Resultados: A média de idade foi de 45,54 (±15,8), sendo 50,8% do sexo feminino e 49,2% do masculino. Uveítes anteriores corresponderam à 63,49% dos casos, intermediárias 1,58% posterior 19,04% e panuveíte 15,87%. Apenas 33,3% dos pacientes encontravam-se com processo inflamatório ativo no momento da avaliação. Cerca de 74,6% das uveítes tinham causas não infecciosas e em 12,69% não foi possível a determinação etiológica. A causa isolada mais frequente foi Espondilite Anquilosante, responsável por 28,57% dos casos. Demonstrou-se que 55,5% dos pacientes tinham acometimento bilateral e 71,14% apresentavam uveíte não granulomatosa. Conclusões: Estudos epidemiológicos que tratam de uveíte são, em geral, realizados em centros terciários de atendimento, que por vezes apresentam perfil etiológico destas inflamações intra-oculares diferente da população geral.

Abstract Objective: To analyze the distribution of uveitis in patients at Uveitis Sector of Federal Hospital of Servants of Rio de Janeiro State. Methods: Retrospective epidemiological study of 63 appointments performed by ophthalmologist of Uveitis Sector at Federal Hospital of Servants of Rio De Janeiro State, between March and October of 2016. Results: The mean age was 45.54 (±15.8). 50.5% were female. Anterior uveitis corresponded to 63.49%. Only 33.3% of patient had an active inflammation at the moment of medical avaliation. 74.6% of uveitis had non-infeccious causes, and in 12.69% the etiology could not be determined. Ankylosing spondylitis was the most frequent cause, responsible for 28.57% of cases. 55.5% of patients had a bilateral uveitis, and 71.14% non-granulomatous uveitis. Conclusions: Epidemiological studies about uveitis are usually made in terciary hospitals, which do not reflect the epidemiological profile of population in general.

Síndrome de nefritis túbulo-intersticial agudo asociado a uveítis / Tubulointerstitial nephritis syndrome and uveitis

La uveítis intermedia es una enfermedad ocular caracterizada por la inflamación de la úvea, principalmente el vítreo anterior, la retina periférica y la pars plana. Diversas etiologías de carácter infeccioso, inflamatorio sistémico y local pueden asociarse a dicho fenómeno. Un cuadro infrecuente es el síndrome de nefritis túbulo-intersticial aguda asociado a uveítis. Presentamos el caso de una mujer de 64 años con antecedente de tiroiditis de Hashimoto, que desarrolló pérdida brusca de la agudeza visual en contexto de falla renal aguda. Se trata de una paciente con nefritis túbulo-intersticial aguda asociada a uveítis.

Intermediate uveitis is described as inflammation in the anterior vitreous, ciliary body and the peripheral retina. It is a subset of uveitis where the vitreous is the major site of damage. It has been reported to be associated with many local and systemic inflammatory and infectious diseases. An infrequent cause is the tubulointerstitial nephritis and uveitis syndrome. We report a case of an acute visual acuity loss related with renal failure in a 64 years old woman with Hashimoto disease. It was an acute tubulointerstitial nephritis and uveitis syndrome case.

A case of atypical nocardia asteroides sclerouveitis resistant to fourth-generation fluoroquinolones / Um caso atípico de esclero-uveíte por Nocardia Asteroides resistente a fluorquinolona de quarta-geração

ABSTRACT We describe an unusual case of Nocardia spp scleritis in a health girl resistant to topical fourth-generation fluoroquinolones. Clinically, there was only partial response of the scleritis to initial therapy. Treatment was changed to meropenem intravenously and topical amikacin. Following several weeks of antibiotic treatment, the patient's infection resolved but her vision was reduced to no light perception. Nocardia asteroides must be considered as a possible agent in cases of necrotizing scleritis in patients without a clear source. Antibiotic sensitivity testing has a definitive role in view of the resistance to these new medications.

RESUMO Nós descrevemos um raro caso de esclerite por Nocardia spp em uma criança sadia resistente a utilização tópica de fluorquinolona de quarta-geração. Clinicamente, a paciente apresentou apenas uma resposta parcial do quadro de esclerite a terapêutica inicial. O tratamento foi então modificado para meropenem intravenoso e amicacina tópica. Após várias semanas de tratamento com antibiótico, o quadro infeccioso regrediu porém a visao da pacientes evoluiu para perda da percepção luminosa. Em casos de esclerite necrotizante em pacientes sem fatores de risco aparente é necessário considerer a Nocardia Asteroides como possível agente causador. Os testes de sensibilidade medicamentosa apresentam importância significativa em virtude do aparecimento de resistência aos novos medicamentos.

Síndrome TINU: revisão de literatura à propósito de um caso / TINU syndrome: review of the literature and case report

Resumo Introdução: A síndrome nefrite tubulointersticial e uveíte (síndrome TINU) é uma entidade clínica incomum e a maioria dos pacientes são adolescentes e mulheres jovens. O caso relatado a seguir refere-se a uma paciente idosa com manifestações oftalmológicas que antecederam às renais, sendo provavelmente o primeiro caso descrito no Brasil. Relato de Caso: Paciente feminina, 60 anos, procurou atendimento médico por queixa de "olhos vermelhos". Três meses após o primeiro episódio do quadro ocular, a paciente cursou com sintomas sistêmicos e disfunção renal. A biópsia renal evidenciou nefrite tubulointersticial com sinais de atividade. Discussão: A fisiopatologia da síndrome TINU permanece pouco entendida, provavelmente envolvendo a imunidade celular e humoral. Essa síndrome pode ser diferenciada de condições sistêmicas associadas à uveíte e à nefrite, sendo necessária a exclusão de outras doenças antes de se confirmar seu diagnóstico, especialmente na presença de achados oftalmológicos. Conclusão: A suspeição clínica e o conhecimento do manejo desta patologia por nefrologistas, internistas e oftalmologistas são mandatórios no tratamento do paciente com Síndrome TINU.

Abstract Introduction: Tubulointerstitial nephritis and uveitis syndrome (TINU Syndrome) is an uncommon clinical entity, and the majority of patients are adolescents and young women. The case reported refers to an elderly patient with ophthalmologic symptoms detected earlier than kidney manifestations, being probably the first case described in Brazil. Case Report: Female patient, 60 years-old, sought medical attention for complaints of "red eye". Three months after the first episode of eye manifestation, the patient presented with systemic symptoms and renal dysfunction. Renal biopsy showed tubulointerstitial nephritis with signs of activity. Discussion: The pathophysiology of TINU Syndrome remains poorly understood, probably involving both cellular and humoral immunity. This syndrome can be differentiated from systemic conditions associated with nephritis and uveitis, and prior exclusion of other diseases is necessary to confirm diagnosis, especially in the presence of ophthalmologic findings. Conclusion: The clinical suspicion and the knowledge of the management of the disease by nephrologists, internists and ophthalmologists is mandatory in the treatment of patients with TINU Syndrome.

Diagnostic Value of the Serum Anti-Toxocara IgG Titer for Ocular Toxocariasis in Patients with Uveitis at a Tertiary Hospital in Korea

PURPOSE: This study evaluated the prevalence of ocular toxocariasis (OT) in patients with uveitis of unknown etiology who visited a tertiary hospital in South Korea and assessed the success of serum anti-Toxocara immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) as a diagnostic test for OT. METHODS: The records of consecutive patients with intraocular inflammation of unknown etiology were reviewed. All participants underwent clinical and laboratory investigations, including ELISA for serum anti-Toxocara IgG. OT was diagnosed based on typical clinical findings. Clinical characteristics, seropositivity, and IgG titers were compared between patients diagnosed with OT and non-OT uveitis. The seropositivity and the diagnostic value of anti-Toxocara IgG was investigated among patients with different types of uveitis. RESULTS: Of 238 patients with uveitis of unknown etiology, 71 (29.8%) were diagnosed with OT, and 80 (33.6%) had positive ELISA results for serum anti-Toxocara IgG. The sensitivity and specificity of the ELISA test were 91.5% (65 / 71) and 91.0% (152 / 167), respectively. The positive predictive value of the serum anti-Toxocara IgG assay was 81.3%. Among patients with anterior, intermediate, posterior, and panuveitis, the prevalence rates of OT were 8.3%, 47.1%, 44.8%, and 7.1%, respectively; the seropositivity percentages were 18.1%, 47.1%, 43.7%, and 17.9%; and the positive predictive values were 38.5%, 95.8%, 92.1%, and 40.0%. The serum anti-Toxocara IgG titer also significantly decreased following albendazole treatment. CONCLUSIONS: OT is a common cause of intraocular inflammation in the tertiary hospital setting. Considering that OT is more prevalent in intermediate and posterior uveitis, and that the positive predictive value of the anti-Toxocara IgG assay is high, a routine test for anti-Toxocara IgG might be necessary for Korean patients with intermediate and posterior uveitis.

Uveítis sifilítica asociada al virus de inmunodeficiencia humana / Syphilitic uveitis associated with the human immunodeficiency virus

La sífilis es una infección crónica y multisistémica, producida por la espiroqueta Treponema pallidum. Las manifestaciones oculares de la sífilis son varias y pueden afectar todas las estructuras oculares. La uveítis es el tipo de afectación ocular más frecuente. Puede presentarse en la fase secundaria, latente o terciaria y cursa de forma bilateral en el 50 por ciento de los casos. También puede verse asociada al virus de inmunodeficiencia humana. Desde la introducción de la terapia antirretroviral de gran actividad, la mortalidad asociada al SIDA disminuyó y la incidencia de sífilis y otras enfermedades de trasmisión sexual aumentó como consecuencia de la expansión de la población homosexual. Teniendo en cuenta la gran variedad de formas de presentación, se le conoce como la gran simuladora y forma parte del diagnóstico diferencial de cualquier uveítis. Presentamos el caso de un paciente masculino de 64 años de edad que acude al Cuerpo de Guardia, donde refiere visión borrosa del ojo derecho de aproximadamente 45 días de evolución, asociado a enrojecimiento ocular, dolor y molestias a la luz, a quien posteriormente se le diagnóstico una uveítis sifilítica asociada al virus de inmunodeficincia humana(AU)

Syphilis is a chronic and multisystemic infection, caused by Treponema Pallidum spirochetes. The ocular manifestations of syphilis are varied and may affect all the ocular structures, being uveítis the most common type of ocular effect. It can appear in the secondary, latent or tertiary phase and in a bilateral form in 50 percent of the cases, it may be associated with the human immunodeficiency virus. Since the introduction of the highly active antiretroviral therapy, AIDS-associated mortality lowered whereas the incidence of syphilis and other sexually transmitted diseases increased as a result of the rise of homosexual population. Due to their great variety in the ways of presentation, syphilis is known as the great simulator and is part of the differential diagnosis of any kind of uveitis. Here is the case of a 64 year-old male patient who went to the Emergency Service, because he felt blurred vision in his right eye for 45 days approximately. Additionally, he presented with eye reddening, pain and discomfort when looking into the light; finally he was diagnosed as human immunodeficiency virus -associated syphilitic uveitis case(AU)